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Ann Thorac Surg 1997;64:1518-1519
© 1997 The Society of Thoracic Surgeons

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Correspondence

Method of Repair of Cocaine-Induced Chronic Type A Aortic Dissection

Division of Cardiothoracic Surgery, Harbor-UCLA, 1000 W Carson St, Box 423, Torrance, CA 90509

To the Editor:

The report by Adkins and associates [1] describing chronic type A dissection as an unusual complication of cocaine abuse was of special interest to us. We have treated several patients at Harbor-UCLA with cocaine-induced type A aortic dissection, 1 of whom had chronic dissection but managed differently than Adkins and associates propose.

Our patient is a 40-year-old woman with a long, active history of cocaine abuse presenting with several weeks of vague chest discomfort. Echocardiography and computed tomographic scanning confirmed type A dissection and aortic insufficiency. She underwent surgical resection of the intimal tear in the ascending aorta using right atrial–femoral bypass. The tissues were thickened and the dissection was a chronic process. The aortic valve cusps were resuspended, the distal true and false lumens were reapposed, and the ascending aorta was replaced with a Hemashield graft (Meadox Medicals, Oakland, NJ). The patient has done well.

In the report by Adkins and associates, the chronic dissection was managed by valve resuspension, resecting the intimal flap, placing an interposition graft, and reinforcing the aorta with felt strips. The true and false lumens were not reapproximated, but allowed to communicate distally. The report concluded that repair in the chronic phase (>2 weeks) of cocaine-induced aortic dissection requires a distal aortic anastomosis to maintain flow into both the true and false lumen.

We do not believe that all such chronic type A dissections need to undergo resection of part of the intimal septum for mandatory perfusion of both true and false lumens. There is often persistence of flow in the false lumen after reapproximation of the true and false lumens during repair of type A aortic dissections, which increases the likelihood of eventual aneurysmal dilatation of the false lumen. One must suppose that leaving a mandatory communication between the true and false lumens would increase the likelihood of this event occurring. We believe that intimal resection to maintain flow to both true and false lumens in cocaine-induced type A dissections is only necessary to avoid imminent malperfusion, as was likely the situation in the patient of Adkins and associates in whom the innominate artery was perfused by the false lumen. The need for intimal resection may also be determined by initiating low-flow cardiopulmonary bypass through the femoral artery with the cross-clamp off and determining lack of retrograde flow through the true lumen.

Reference

1. Adkins MS, Gaines WE, Anderson WA, Laub GW, Fernandez J, McGrath LB. Chronic type A aortic dissection: an unusual complication of cocaine inhalation. Ann Thorac Surg 1993;56:977–9.[Abstract/Free Full Text]

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baumgartner, F. J. Articles by Omari, B. O. Search for Related Content PubMed PubMed Citation Articles by Baumgartner, F. J. Articles by Omari, B. O.